Retreat Seva Option Application

Lodging*

Where will you be staying?*

Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Age*

Emergency Contact Name*

First Last

Emergency Contact Phone*

Emergency Contact Relation*

Do you have health insurance?*

Do you have any medical conditions that will limit your ability to assist in any projects?*

Please list medical condition(s)*

Are you taking any prescribed medications?*

Please list prescribed medication(s)*

Have you had any mental or emotional conditions that required professional help?*

Please list mental/emotional condition(s)*

Any history of addiction?*

Please describe addiction history.*

Do you have any diet restrictions or eating habits we should know about?*

Please describe diet restrictions/eating habits.*

We recommend that you practice Surya Ram Meditation twice daily for at least 2 weeks before attending the retreat.

Do you practice the Surya Ram Meditation or Transcendental Meditation?*

Work history, hobbies, skills, and interests*

Name (as signature)*

Today's Date*

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